Form RL-11d (11-02) RL-11d (11-02) Disclosure of Medical Records from a State Agency

Form Approved
OMB NO.3220-0038

In reply refer to

REQUEST FOR WORKERS COMPENSATIONIPUBLIC DISABII-ITY BENEFIT
NlEDlCAL EVIDENCE
The person named below has applied for or is receiving disability benefits under the Railroad
Retirement Act. To assist us in determining whether such benefits are payable, please furnish
copies of any records describing this person's disability as well as any medical records you have
including:
transcripts of in-hospital and out-patient treatment;
transcripts of examinations for compensation or pension; and
transcripts of any vocational training.
Send the records as soon as possible to the Railroad Retirement Board (RRB) address shown
above. Be sure to include the person's RRB claim number in your reply. If, for any reason, you are
unable to furnish medical records, please notify this office immediately.
Since the RRB is an agency of the United States Government, the information should generally be
furnished without charge. It is needed to establish entitlement to benefits under a federal law.
Authorization to release medical information to the RRB is enclosed. Your cooperation in
furnishing the required information as soon as possible will be appreciated. Patient identifying
information follows.

RRB Form RL- 11D (11-02)

IDENTIFYING INFORMATION
Name and Address of ApplicantIAnnuitant:

Social Securitv No.:
Date of Birth:
Worker's Compensation or Disability Benefit Beqinninq Date:
Employing Agency or Company:
Claim No. at Emploving Agencv or Companv:
Period of Disabilitv:
Nature of Disabilitv:
Other Identifving Information:
Sincerely,

Enclosure
Form G-197

PAPERWORK REDUCTION ACT NO'I'ICE
We estimate this form takes an average of 10 minutes per response to complete, includiqg time for reviewing
the instructions, getting the needed data, and reviewing the completed form. Federal agencies may not
conduct or sponsor, and respondents are not required to respond to, a collectiqn of information unless it
displays a valid OMB number. If you wish, send comments regarding the accuracy of our estimate or any
other aspect of this form, including suggestions for reducing completion time to: Chief of Information
Resources Management, Railroad Retirement Board, 844 N. Rush Street, Chicqgo, IL 6061 1-2092.

RRB Form RL-11D (1 1-02)